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Rohit RK, Tibrewal C, Modi NS, Bajoria PS, Dave PA, Gandhi SK, Patel P. Effectiveness of Induced Hypothermia on the Prognosis of Post-cardiac Arrest Patients: A Scoping Literature Review. Cureus 2023; 15:e43064. [PMID: 37680442 PMCID: PMC10481631 DOI: 10.7759/cureus.43064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/09/2023] Open
Abstract
Cardiac arrest (CA) is one of the leading causes of death worldwide. Therapeutic hypothermia (TH) is hypothesized to be a reliable practice for better prognosis in post-cardiac arrest (PCA) patients. Medical subject headings (MeSH) terminology was used to search PubMed Central, Medline, and PubMed databases for articles on the use of hypothermia in PCA patients. We selected various clinical trials, meta-analyses and review articles with complete texts in the English language. PCA syndrome occurs after a CA where the body experiences a state of global ischemia and multi-system dysfunction due to the release of reactive oxygen species (ROS) and inflammatory mediators. Hypothermia slows down enzymatic reactions, reduces free radical production, conserves energy, and prevents the accumulation of metabolic waste products. Delaying the time to initiate targeted temperature management (TTM) increases the mortality of patients, the appropriate temperature for TTM has always been debatable. TTM also has various deleterious effects on various organ systems from shivering, and arrhythmias to life-threatening infections but the risks outweigh the benefits for the patients when hypothermia is introduced in PCA care. Our study compares the different modalities to initiate hypothermia from surface cooling devices to intravascular cooling devices, and the adverse effects of each method compared to another.
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Affiliation(s)
- Ralph Kingsford Rohit
- Department of Internal Medicine, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Charu Tibrewal
- Department of Internal Medicine, Civil Hospital Ahmedabad, Ahmedabad, IND
| | | | - Parth S Bajoria
- Department of Internal Medicine, Gujarat Medical Education and Research Society, Gandhinagar, IND
| | | | - Siddharth Kamal Gandhi
- Department of Internal Medicine, Shri M. P. Shah Government Medical College, Jamnagar, IND
| | - Priyansh Patel
- Department of Internal Medicine, Medical College Baroda, Vadodara, IND
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2
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Bian W, Bian W, Li Y, Feng X, Song M, Zhou P. Hypothermia may reduce mortality and improve neurologic outcomes in adult patients treated with VA-ECMO: A systematic review and meta-analysis. Am J Emerg Med 2023; 70:163-170. [PMID: 37327682 DOI: 10.1016/j.ajem.2023.05.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/08/2023] [Accepted: 05/21/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND VA-ECMO can greatly reduce mortality in critically ill patients, and hypothermia attenuates the deleterious effects of ischemia-reperfusion injury. We aimed to study the effects of hypothermia on mortality and neurological outcomes in VA-ECMO patients. METHODS A systematic search of the PubMed, Embase, Web of Science, and Cochrane Library databases was performed from the earliest available date to 31 December 2022. The primary outcome was discharge or 28-day mortality and favorable neurological outcomes in VA-ECMO patients, and the secondary outcome was bleeding risk in VA-ECMO patients. The results are presented as odds ratios (ORs) and 95% confidence intervals (CIs). Based on the heterogeneity assessed by the I2 statistic, meta-analyses were performed using random or fixed-effects models. GRADE methodology was used to rate the certainty in the findings. RESULTS A total of 27 articles (3782 patients) were included. Hypothermia (33-35 °C) lasting at least 24 h can significantly reduce discharge or 28-day mortality (OR, 0.45; 95% CI, 0.33-0.63; I2 = 41%) and significantly improve favorable neurological outcomes (OR, 2.08; 95% CI, 1.66-2.61; I2 = 3%) in VA-ECMO patients. Additionally, there was no risk associated with bleeding (OR, 1.15; 95% CI, 0.86-1.53; I2 = 12%). In our subgroup analysis according to in-hospital or out-of-hospital cardiac arrest, hypothermia reduced short-term mortality in both VA-ECMO-assisted in-hospital (OR, 0.30; 95% CI, 0.11-0.86; I2 = 0.0%) and out-of-hospital cardiac arrest (OR, 0.41; 95% CI, 0.25-0.69; I2 = 52.3%). Out-of-hospital cardiac arrest patients assisted by VA-ECMO for favorable neurological outcomes were consistent with the conclusions of this paper (OR, 2.10; 95% CI, 1.63-2.72; I2 = 0.5%). CONCLUSIONS Our results show that mild hypothermia (33-35 °C) lasting at least 24 h can greatly reduce short-term mortality and significantly improve favorable short-term neurologic outcomes in VA-ECMO-assisted patients without bleeding-related risks. As the grade assessment indicated that the certainty of the evidence was relatively low, hypothermia as a strategy for VA-ECMO-assisted patient care may need to be treated with caution.
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Affiliation(s)
- Wentao Bian
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Wenkai Bian
- Xi'an Radio Research Institute, Xian, Shaanxi Province, China
| | - Yi Li
- Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Xuanlin Feng
- Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Menglong Song
- Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Ping Zhou
- Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China.
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Moreau A, Levy B, Annoni F, Lorusso R, Su F, Belliato M, Taccone FS. The use of induced hypothermia in extracorporeal membrane oxygenation: A narrative review. Resusc Plus 2023; 13:100360. [PMID: 36793940 PMCID: PMC9922920 DOI: 10.1016/j.resplu.2023.100360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/28/2022] [Accepted: 01/09/2023] [Indexed: 01/29/2023] Open
Abstract
Despite venovenous or venoarterial extracorporeal membrane oxygenation (ECMO) being increasingly used in patients with severe acute respiratory disease syndrome, severe cardiogenic shock, and refractory cardiac arrest, mortality rates still remain high mainly because of the severity of the underlying disease and the numerous complications associated with initiation of ECMO. Induced hypothermia might minimize several pathological pathways present in patients requiring ECMO; even though numerous studies conducted in the experimental setting have reported promising results, there are currently no recommendations suggesting the routine use of this therapy in patients requiring ECMO. In this review, we summarized the existing evidence on the use of induced hypothermia in patients requiring ECMO. Induced hypothermia was a feasible and relatively safe intervention in this setting; however, the effects on clinical outcomes remain uncertain. Whether controlled normothermia has an impact on these patients compared with no temperature control remains unknown. Further randomized controlled trials are required to better understand the role and impact of such therapy in patients requiring ECMO according to the underlying disease.
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Affiliation(s)
- Anthony Moreau
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium,Laboratoire Expérimental des Soins Intensifs, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Bruno Levy
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy, France,INSERM U1116, Faculté de Médecine, Université de Lorraine, 54000 Nancy, France
| | - Filippo Annoni
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium,Laboratoire Expérimental des Soins Intensifs, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Fuhong Su
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium,Laboratoire Expérimental des Soins Intensifs, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Mirko Belliato
- UOC AR 2-Anestesia e Rianimazione Cardiotoracica Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium,Laboratoire Expérimental des Soins Intensifs, Université Libre de Bruxelles (ULB), Brussels, Belgium,Corresponding author at: Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070 Brussels, Belgium.
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Watanabe M, Matsuyama T, Miyamoto Y, Kitamura T, Komukai S, Ohta B. The impact of different targeted temperatures on out-of-hospital cardiac arrest outcomes in patients receiving extracorporeal membrane oxygenation: a nationwide cohort study. Crit Care 2022; 26:380. [PMID: 36482479 PMCID: PMC9733046 DOI: 10.1186/s13054-022-04256-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Targeted temperature management (TTM) is recommended in the management of out-of-hospital cardiac arrest (OHCA) when coma persists after the return of spontaneous circulation. In the setting of extracorporeal membrane oxygenation (ECMO) for OHCA patients, TTM is associated with good neurological outcomes and is recommended in the Extracorporeal Life Support Organization guidelines. However, the optimal targeted temperature for these patients has not yet been adequately investigated. This study aimed to compare the impact of different targeted temperatures on the outcomes in OHCA patients receiving ECMO. METHODS This was a retrospective analysis of data from the Japanese Association for Acute Medicine (JAAM)-OHCA Registry, a multicentre nationwide prospective database in Japan in which 103 institutions providing emergency care participated. OHCA patients aged ≥ 18 years who required ECMO with TTM between June 2014 and December 2019 were included in our analysis. The primary outcome was 30-day survival with favourable neurological outcomes, defined as a Glasgow-Pittsburgh cerebral performance category score of 1 or 2. Patients were divided into two groups according to their targeted temperature: normothermic TTM (n-TTM) (35-36 °C) and hypothermic TTM (h-TTM) (32-34 °C). We compared the outcomes between the two targeted temperature groups using multivariable logistic regression and inverse probability weighting (IPW). RESULTS A total of 890 adult OHCA patients who received ECMO and TTM were eligible for our analysis. Of these patients, 249 (28%) and 641 (72%) were treated with n-TTM and h-TTM, respectively. The proportions of patients with 30-day favourable neurological outcomes were 16.5% (41/249) and 15.9% (102/641), in the n-TTM and h-TTM groups, respectively. No difference in neurological outcomes was observed in the multiple regression analysis [adjusted odds ratio 0.91, 95% confidence interval (CI) 0.58-1.43], and the result was constant in the IPW (odds ratio 1.01, 95% CI 0.67-1.54). CONCLUSION No difference was observed between n-TTM and h-TTM in OHCA patients receiving TTM with ECMO. The current understanding that changes to the targeted temperature have little impact on the outcome of patients may remain true regardless of ECMO use.
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Affiliation(s)
- Makoto Watanabe
- grid.272458.e0000 0001 0667 4960Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566 Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Yuki Miyamoto
- grid.272458.e0000 0001 0667 4960Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566 Japan
| | - Tetsuhisa Kitamura
- grid.136593.b0000 0004 0373 3971Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka Suita, Osaka, 565-0871 Japan
| | - Sho Komukai
- grid.136593.b0000 0004 0373 3971Division of Biomedical Statistics Department of Integrated Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Bon Ohta
- grid.272458.e0000 0001 0667 4960Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566 Japan
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Nishihara M, Hiasa KI, Enzan N, Ichimura K, Iyonaga T, Shono Y, Kashiura M, Moriya T, Kitazono T, Tsutsui H. Hyperoxemia is Associated With Poor Neurological Outcomes in Patients With Out-of-Hospital Cardiac Arrest Rescued by Extracorporeal Cardiopulmonary Resuscitation: Insight From the Nationwide Multicenter Observational JAAM-OHCA (Japan Association for Acute Medicine) Registry. J Emerg Med 2022; 63:221-231. [PMID: 36038433 DOI: 10.1016/j.jemermed.2022.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/05/2022] [Accepted: 05/09/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Previous studies have shown an association between hyperoxemia and mortality in patients with out-of-hospital cardiac arrest (OHCA) after cardiopulmonary resuscitation (CPR); however, evidence is lacking in the extracorporeal CPR (ECPR) setting. OBJECTIVE The aim of this study was to test the hypothesis that hyperoxemia is associated with poor neurological outcomes in patients treated by ECPR. METHODS The Japanese Association for Acute Medicine OHCA Registry is a multicenter, prospective, observational registry of patients from 2014 to 2017. Adult (18 years or older) patients who had undergone ECPR after OHCA were included. Eligible patients were divided into two groups based on the partial pressure of oxygen in arterial blood (PaO2) levels at 24 h after ECPR: the high-PaO2 group (n = 242) defined as PaO2 ≥ 157 mm Hg (median) and the low-PaO2 group (n = 211) defined as PaO2 60 to < 157 mm Hg. The primary outcome was the favorable neurological outcome, defined as a Cerebral Performance Categories Scale score of 1 to 2 at 30 days after OHCA. RESULTS Of 34,754 patients with OHCA, 453 patients were included. The neurological outcome was significantly lower in the high-PaO2 group than in the low-PaO2 group (15.9 vs. 33.5%; p < 0.001). After adjusting for potential confounders, high PaO2 was negatively associated with favorable neurological outcomes (adjusted odds ratio [aOR] 0.48; 95% confidence interval [CI] 0.24-0.97; p = 0.040). In a multivariate analysis with multiple imputation, high PaO2 was also negatively associated with favorable neurological outcomes (aOR 0.63; 95% CI 0.49-0.81; p < 0.001). CONCLUSIONS Hyperoxemia was associated with worse neurological outcomes in OHCA patients with ECPR.
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Affiliation(s)
- Masaaki Nishihara
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan; Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Ken-Ichi Hiasa
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nobuyuki Enzan
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenzo Ichimura
- School of Medicine, Pulmonary, Allergy and Critical Care Medicine, Stanford University, Stanford, California
| | - Takeshi Iyonaga
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan; Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Yuji Shono
- Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Masahiro Kashiura
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Takashi Moriya
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Takanari Kitazono
- Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
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Kim HJ, Youn CS, Park KN, Kim YM, Lee BK, Jeung KW, Kim WY, Choi SP, Kim SH. The association of different target temperatures in targeted temperature management with neurological outcome after out-of-hospital cardiac arrest based on a prospective multicenter observational study in Korea (the KORHN-PRO registry): IPTW analysis. PLoS One 2022; 17:e0271605. [PMID: 35867664 PMCID: PMC9307160 DOI: 10.1371/journal.pone.0271605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/01/2022] [Indexed: 11/18/2022] Open
Abstract
Background Among comatose survivors of out-of-hospital cardiac arrest (OHCA), targeted temperature management (TTM) has improved neurological outcomes. However, although the target temperature shifted from 33°C to 33°C~36°C, the optimal target temperature is still unclear. The goal of this study was to evaluate neurological outcomes at 6 months at target temperatures of 33°C and 36°C. Materials and methods We analyzed OHCA survivors who underwent TTM and were recorded in the Korean Hypothermia Network, a prospective multicenter registry, from October 2015 to December 2018. The primary outcome was good neurological outcome at six months, defined as a cerebral performance category of 1–2, and the secondary outcome was survival at 6 months. Results A total of 1339 patients were treated with TTM in twenty-two emergency departments. Of those, 1054 were treated at 33°C, and 285 were treated at 36°C. There was no significant difference in good neurological outcomes at 6 months (30.6% vs. 31.2%, p = 0.850, adjusted OR 0.97, 95% CI = 0.73–1.29]) and survival at six months (41.4% vs. 38.7%, p = 0.401, adjusted HR 1.08, 95% CI = 0.91–1.28]) between TTM 33°C and TTM 36°C. After propensity score matching, good neurological outcomes at 6 months (OR 0.93, 95% CI = 0.74–1.18) and survival at 6 months (HR 1.05, 95% CI = 0.92–1.21) were still not associated with TTM 33°C and TTM 36°C. Conclusion In this study, patients treated with a target temperature of 33°C had similar good neurological outcomes and survival at six months compared with those treated with a target temperature of 36°C.
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Affiliation(s)
- Hyo Joon Kim
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Young-Min Kim
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Donggu, Gwangju, Republic of Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Donggu, Gwangju, Republic of Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung Pill Choi
- Department of Emergency Medicine, Eunpyeong St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Soo Hyun Kim
- Department of Emergency Medicine, Eunpyeong St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
- * E-mail:
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Hillerson DB, Laine ME, Bissell BD, Mefford B. Contemporary targeted temperature management: Clinical evidence and controversies. Perfusion 2022; 38:666-680. [PMID: 35531914 DOI: 10.1177/02676591221076286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Advancements in cardiac arrest and post-cardiac arrest care have led to improved survival to hospital discharge. While survival to hospital discharge is an important clinical outcome, neurologic recovery is also a priority. With the advancement of targeted temperature management (TTM), the American Heart Association guidelines for post-cardiac arrest care recommend TTM in patients who remain comatose after return of spontaneous circulation (ROSC). Recently, the TTM2 randomized controlled trial found no significant difference in neurologic function and mortality at 6-months between traditional hypothermia to 33°C versus 37.5°C. While TTM has been evaluated for decades, current literature suggests that the use of TTM to 33° when compared to a protocol of targeted normothermia does not result in improved outcomes. Instead, perhaps active avoidance of fever may be most beneficial. Extracorporeal cardiopulmonary resuscitation and membrane oxygenation can provide a means of both hemodynamic support and TTM after ROSC. This review aims to describe the pathophysiology, physiologic aspects, clinical trial evidence, changes in post-cardiac arrest care, potential risks, as well as controversies of TTM.
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Affiliation(s)
- Dustin B Hillerson
- 5232University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Colls Garrido C, Riquelme Gallego B, Sánchez García JC, Cortés Martín J, Montiel Troya M, Rodríguez Blanque R. The Effect of Therapeutic Hypothermia after Cardiac Arrest on the Neurological Outcome and Survival-A Systematic Review of RCTs Published between 2016 and 2020. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182211817. [PMID: 34831572 PMCID: PMC8618610 DOI: 10.3390/ijerph182211817] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/04/2021] [Accepted: 11/07/2021] [Indexed: 01/10/2023]
Abstract
Therapeutic hypothermia is a treatment used for patients who have suffered cardiorespiratory arrest and remain conscious after the recovery of spontaneous circulation. However, its effectiveness is controversial. The objective of this systematic review is to summarize the scientific evidence available about the effect of therapeutic hypothermia on neurological status and survival in this type of patients. METHODOLOGY A primary search in CINAHL, CUIDEN, Pubmed, Web of Science, and Scopus databases was carried out. Randomized clinical trials (RCT) published from 2016 to 2020 were selected. RESULTS 17 studies were selected for inclusion and most relevant data were extracted. Methodological quality was assessed by the RoB tool. CONCLUSIONS Although therapeutic hypothermia is a safe technique with few adverse and manageable effects, it has not shown to improve survival rate and neurological status of adult nor pediatric patients. It is possible that its positive effect on neuroprotection could be achieved only by preventing hyperthermia although further investigation is needed.
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Affiliation(s)
| | - Blanca Riquelme Gallego
- School of Nursing, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain; (J.C.S.G.); (J.C.M.)
- Instituto de Investigación Biosanitaria, ibs.GRANADA, 18012 Granada, Spain
- Correspondence:
| | - Juan Carlos Sánchez García
- School of Nursing, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain; (J.C.S.G.); (J.C.M.)
- Research Group CTS1068, Andalusia Research Plan, Junta de Andalucía, 18014 Granada, Spain; (M.M.T.); (R.R.B.)
| | - Jonathan Cortés Martín
- School of Nursing, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain; (J.C.S.G.); (J.C.M.)
- Research Group CTS1068, Andalusia Research Plan, Junta de Andalucía, 18014 Granada, Spain; (M.M.T.); (R.R.B.)
| | - María Montiel Troya
- Research Group CTS1068, Andalusia Research Plan, Junta de Andalucía, 18014 Granada, Spain; (M.M.T.); (R.R.B.)
- School of Nursing Ceuta Campus, Faculty of Health Sciences, University of Granada, 51001 Ceuta, Spain
| | - Raquel Rodríguez Blanque
- Research Group CTS1068, Andalusia Research Plan, Junta de Andalucía, 18014 Granada, Spain; (M.M.T.); (R.R.B.)
- Distrito Sanitario Granada-Metropolitano, 18013 Granada, Spain
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Wilcox C, Choi CW, Cho SM. Brain injury in extracorporeal cardiopulmonary resuscitation: translational to clinical research. JOURNAL OF NEUROCRITICAL CARE 2021. [DOI: 10.18700/jnc.210016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The addition of extracorporeal membrane oxygenation (ECMO) to conventional cardiopulmonary resuscitation (CPR), termed extracorporeal cardiopulmonary resuscitation (ECPR), has significantly improved survival in selected patient populations. Despite this advancement, significant neurological impairment persists in approximately half of survivors. ECPR represents a potential advancement for patients who experience refractory cardiac arrest (CA) due to a reversible etiology and do not regain spontaneous circulation. Important risk factors for acute brain injury (ABI) in ECPR include lack of perfusion, reperfusion, and altered cerebral autoregulation. The initial hypoxic-ischemic injury caused by no-flow and low-flow states after CA and during CPR is compounded by reperfusion, hyperoxia during ECMO support, and nonpulsatile blood flow. Additionally, ECPR patients are at risk for Harlequin syndrome with peripheral cannulation, which can lead to preferential perfusion of cerebral vessels with deoxygenated blood. Lastly, the oxygenator membrane is prothrombotic and requires systemic anticoagulation. The two competing phenomena result in thrombus formation, hemolysis, and thrombocytopenia, increasing the risk of ischemic and hemorrhagic ABI. In addition to clinical studies, we assessed available ECPR animal models to identify the mechanisms underlying ABI at the cellular level. Standardized multimodal neurological monitoring may facilitate early detection of and intervention for ABI. With the increasing use of ECPR, it is critical to understand the pathophysiology of ABI, its prevention, and the management strategies for improving the outcomes of ECPR. Translational and clinical research focusing on acute ABI immediately after ECMO cannulation and its short- and long-term neurological outcomes are warranted.
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Duan J, Ma Q, Zhu C, Shi Y, Duan B. eCPR Combined With Therapeutic Hypothermia Could Improve Survival and Neurologic Outcomes for Patients With Cardiac Arrest: A Meta-Analysis. Front Cardiovasc Med 2021; 8:703567. [PMID: 34485403 PMCID: PMC8414549 DOI: 10.3389/fcvm.2021.703567] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/28/2021] [Indexed: 01/01/2023] Open
Abstract
Background: Extracorporeal membrane oxygenation with CPR (eCPR) or therapeutic hypothermia (TH) seems to be a very effective CPR strategy to save patients with cardiac arrest (CA). Furthermore, the subsequent post-CA neurologic outcomes have become the focus. Therefore, there is an urgent need to find a way to improve survival and neurologic outcomes for CA. Objective: We conducted this meta-analysis to find a more suitable CPR strategy for patients with CA. Method: We searched four online databases (PubMed, Embase, CENTRAL, and Web of Science). From an initial 1,436 articles, 23 studies were eligible into this meta-analysis, including a total of 2,035 patients. Results: eCPR combined with TH significantly improved the short-term (at discharge or 28 days) survival [OR = 2.27, 95% CIs (1.60-3.23), p < 0.00001] and neurologic outcomes [OR = 2.60, 95% CIs (1.92-3.52), p < 0.00001). At 3 months of follow-up, the results of survival [OR = 3.36, 95% CIs (1.65-6.85), p < 0.0008] and favorable neurologic outcomes [OR = 3.02, 95% CIs (1.38-6.63), p < 0.006] were the same as above. Furthermore, there was no difference in any bleeding needed intervention [OR = 1.33, 95% CIs (0.09-1.96), p = 0.16] between two groups. Conclusions: From this meta-analysis, we found that eCPR combined with TH might be a more suitable CPR strategy for patients with CA in improving survival and neurologic outcomes, and eCPR with TH did not increase the risk of bleeding. Furthermore, single-arm meta-analyses showed a plausible way of temperature and occasion of TH.
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Affiliation(s)
- Jingwei Duan
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Qingbian Ma
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Changju Zhu
- Emergency Department, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuanchao Shi
- The First Clinical Medicine School, Lanzhou University, Lanzhou, China
| | - Baomin Duan
- Emergency Department, Kaifeng Centre Hospital, Kaifeng, China
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11
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Tahara Y, Noguchi T, Yonemoto N, Nakashima T, Yasuda S, Kikuchi M, Hashiba K, Arimoto H, Nishioka K, Kokubu N, Atsumi T, Kashiwase K, Kasaoka S, Kuroda Y, Kada A, Yokoyama H, Nonogi H. Cluster Randomized Trial of Duration of Cooling in Targeted Temperature Management After Resuscitation for Cardiac Arrest. Circ Rep 2021; 3:368-374. [PMID: 34250277 PMCID: PMC8258184 DOI: 10.1253/circrep.cr-21-0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 11/09/2022] Open
Abstract
Background: The 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommend that comatose patients with return of spontaneous circulation after cardiac arrest have targeted temperature management (TTM). However, the duration of TTM remains to be elucidated. Methods and Results: We conducted a cluster randomized trial in 10 hospitals to compare 12-24 vs. 36 h of cooling in patients with cardiac arrest who received TTM. The primary outcome was the incidence, within 1 month, of complications including bleeding requiring transfusion, infection, arrhythmias, decreasing blood pressure, shivering, convulsions, and major adverse cardiovascular events. Secondary outcomes were mortality and favorable neurological outcome (Cerebral Performance Categories 1-2) at 3 months. Random-effects models with clustered effects were used to calculate risk ratios (RR). Data of 185 patients were analyzed (12- to 24-h group, n=100 in 5 hospitals; 36-h group, n=85 in 5 hospitals). The incidence of complications within 1 month did not differ between the 2 groups (40% vs. 34%; RR 1.04, 95% confidence interval [CI] 0.67-1.61, P=0.860). Favorable neurological outcomes at 3 months were comparable between the 2 groups (64% vs. 62%; RR 0.91, 95% CI 0.72-1.14, P=0.387). Conclusions: TTM at 34℃ for 12-24 h did not significantly reduce the incidence of complications. This study did not show superiority of TTM at 34℃ for 12-24 h for neurologic outcomes.
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Affiliation(s)
- Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center Suita Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center Suita Japan
| | - Naohiro Yonemoto
- Department of Public Health, Juntendo University School of Medicine Tokyo Japan.,Department of Psychoneuropharmacology, National Center of Neurology and Psychiatry Kodaira Japan
| | - Takahiro Nakashima
- Department of Emergency Medicine, University of Michigan Ann Arbor, MI USA
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center Suita Japan.,Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine Sendai Japan
| | - Migaku Kikuchi
- Department of Cardiovascular Medicine/Emergency and Critical Care Center, Dokkyo Medical University Tochigi Japan
| | - Katsutaka Hashiba
- Department of Cardiology, Saiseikai Yokohama-shi Nanbu Hospital Yokohama Japan
| | - Hideki Arimoto
- Department of Emergency Medicine and Critical Care, Iseikai Hospital Osaka Japan
| | - Kenji Nishioka
- Department of Cardiology, Hiroshima City Hiroshima Citizens Hospital Hiroshima Japan
| | - Nobuaki Kokubu
- Advanced Critical Care and Emergency Center, Sapporo Medical University Hospital Sapporo Japan
| | - Takahiro Atsumi
- Department of Emergency Medicine, Seirei Hamamatsu General Hospital Hamamatsu Japan
| | | | - Shunji Kasaoka
- Disaster Medical Education and Research Center, Kumamoto University Hospital Kumamoto Japan
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University Kagawa Japan
| | - Akiko Kada
- National Hospital Organization Nagoya Medical Center Nagoya Japan
| | - Hiroyuki Yokoyama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center Suita Japan
| | - Hiroshi Nonogi
- Faculty of Health Science, Osaka Aoyama University Osaka Japan
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12
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Chen X, Zhen Z, Na J, Wang Q, Gao L, Yuan Y. Associations of therapeutic hypothermia with clinical outcomes in patients receiving ECPR after cardiac arrest: systematic review with meta-analysis. Scand J Trauma Resusc Emerg Med 2020; 28:3. [PMID: 31937354 PMCID: PMC6961259 DOI: 10.1186/s13049-019-0698-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 12/30/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia has been recommended for eligible patients after cardiac arrest (CA) in order to improve outcomes. Up to now, several comparative observational studies have evaluated the combined use of extracorporeal cardiopulmonary resuscitation (ECPR) and therapeutic hypothermia in adult patients with CA. However, the effects of therapeutic hypothermia in adult CA patients receiving ECPR are inconsistent. METHODS Relevant studies in English databases (PubMed, ISI web of science, OVID, and Embase) were systematically searched up to September 2019. Odds ratios (ORs) from eligible studies were extracted and pooled to summarize the associations of therapeutic hypothermia with favorable neurological outcomes and survival in adult CA patients receiving ECPR. RESULTS 13 articles were included in the present meta-analysis study. There were nine studies with a total of 806 cases reporting the association of therapeutic hypothermia with neurological outcomes in CA patients receiving ECPR. Pooling analysis suggested that therapeutic hypothermia was significantly associated with favorable neurological outcomes in overall (N = 9, OR = 3.507, 95%CI = 2.194-5.607, P < 0.001, fixed-effects model) and in all subgroups according to control type, regions, sample size, CA location, ORs obtained methods, follow-up period, and modified Newcastle Ottawa Scale (mNOS) scores. There were nine studies with a total of 806 cases assessing the association of therapeutic hypothermia with survival in CA patients receiving ECPR. After pooling the ORs, therapeutic hypothermia was found to be significantly associated with survival in overall (N = 9, OR = 2.540, 95%CI = 1.245-5.180, P = 0.010, random-effects model) and in some subgroups. Publication bias was found when evaluating the association of therapeutic hypothermia with neurological outcomes in CA patients receiving ECPR. Additional trim-and-fill analysis estimated four "missing" studies, which adjusted the effect size to 2.800 (95%CI = 1.842-4.526, P < 0.001, fixed-effects model) for neurological outcomes. CONCLUSIONS Therapeutic hypothermia may be associated with favorable neurological outcomes and survival in adult CA patients undergoing ECPR. However, the result should be treated carefully because it is a synthesis of low-level evidence and other limitations exist in present study. It is necessary to perform randomized controlled trials to validate our result before considering the result in clinical practices.
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Affiliation(s)
- Xi Chen
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Zhen Zhen
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Jia Na
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Qin Wang
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Lu Gao
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Yue Yuan
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
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13
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Callahan SJ, Pal K, Jones RM, Davis EM, Kadl A. Temperature Control after Cardiac Arrest. When to Start? How Long? How Cold? Am J Respir Crit Care Med 2019; 198:1331-1333. [PMID: 30199655 DOI: 10.1164/rccm.201711-2269rr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sean J Callahan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Kavita Pal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Robert M Jones
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Eric M Davis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Alex Kadl
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia
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14
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Kleissner M, Sramko M, Kautzner J, Kettner J. Mid-term clinical outcomes of out-of-hospital cardiac arrest patients treated with targeted temperature management at 34–36 °C versus 32–34 °C. Heart Lung 2019; 48:273-277. [DOI: 10.1016/j.hrtlng.2018.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 11/25/2018] [Accepted: 11/27/2018] [Indexed: 12/16/2022]
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15
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Abstract
Therapeutic hypothermia, or targeted temperature management (TTM), is a strategy of reducing the core body temperature of survivors of sudden cardiac arrest (SCA) to minimize neurological damage caused by severe hypoxia. Initial clinical trials examining this technique demonstrated significant improvement in neurological function among survivors of out-of-hospital SCA with an initial shockable rhythm. Since then, TTM has become an integral part of the care provided to comatose survivors of SCA. However, multiple questions persist regarding the target cooling temperature, duration of cooling, and utility of TTM in patient populations such as survivors of out-of-hospital SCA with non-shockable rhythms or in-hospital SCA. This review article summarizes the current evidence regarding optimal application of TTM and compares the recommendations for TTM in current guidelines.
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16
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Cho E, Lee SE, Park E, Kim HH, Lee JS, Choi S, Min YG, Chae MK. Pilot study on a rewarming rate of 0.15°C/hr versus 0.25°C/hr and outcomes in post cardiac arrest patients. Clin Exp Emerg Med 2019; 6:25-30. [PMID: 30781943 PMCID: PMC6453687 DOI: 10.15441/ceem.17.275] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 10/26/2017] [Indexed: 11/23/2022] Open
Abstract
Objective Cerebral hemodynamic and metabolic changes may occur during the rewarming phase of targeted temperature management in post cardiac arrest patients. Yet, studies on different rewarming rates and patient outcomes are limited. This study aimed to investigate post cardiac arrest patients who were rewarmed with different rewarming rates after 24 hours of hypothermia and the association of these rates to the neurologic outcomes. Methods This study retrospectively investigated post cardiac arrest patients treated with targeted temperature management and rewarmed with rewarming rates of 0.15°C/hr and 0.25°C/hr. The association of the rewarming rate with poor neurologic outcomes (cerebral performance category score, 3 to 5) was investigated. Results A total of 71 patients were analyzed (0.15°C/hr, n=36; 0.25°C/hr, n=35). In the comparison between 0.15°C/hr and 0.25°C/hr, the poor neurologic outcome did not significantly differ (24 [66.7%] vs. 25 [71.4%], respectively; P=0.66). In the multivariate analysis, the rewarming rate of 0.15°C/hr was not associated with the 1-month neurologic outcome improvement (odds ratio, 0.54; 95% confidence interval, 0.16 to 1.69; P=0.28). Conclusion The rewarming rates of 0.15°C/hr and 0.25°C/hr were not associated with the neurologic outcome difference in post cardiac arrest patients.
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Affiliation(s)
- Eunhye Cho
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Sung Eun Lee
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Eunjung Park
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Hyuk-Hoon Kim
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Ji Sook Lee
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Sangchun Choi
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Young Gi Min
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Minjung Kathy Chae
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
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17
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Kirkegaard H, Taccone FS, Skrifvars MB, Søreide E. How long should comatose patients resuscitated from cardiac arrest be cooled? J Thorac Dis 2018; 10:E761-E763. [PMID: 30505521 DOI: 10.21037/jtd.2018.09.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Hans Kirkegaard
- Research Center for Emergency Medicine, Emergency Department & Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Markus B Skrifvars
- Department of Emergency Care and Services and Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Eldar Søreide
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway and Department of Clinical Medicine, University of Bergen, Bergen, Norway
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18
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Abstract
Therapeutic hypothermia, also referred to as targeted temperature management, has been a component of the postcardiac arrest treatment guidelines since 2010. Although almost a decade has passed since its inclusion in the postarrest guidelines, many unanswered questions remain regarding selection of the appropriate patient population, optimal target temperature, ideal window of time in which to initiate therapy after arrest, most efficient, safe, and accurate equipment choice for inducing and maintaining hypothermia, most effective duration of treatment, and rate of cooling or rewarming. On a national and international level, critical care nurses are in a unique position to participate in research that will define targeted temperature management protocols and practices. Nurses are also ideal for standardizing the targeted temperature management policy and protocol locally and nationally based on current available evidence. This review aims to serve 2 purposes: first, to provide a broad update on the current clarifications and limitations per research findings on target temperature management therapy; second, to explain how critical care nurses can use this updated information to improve outcomes for their patients with cardiac arrest.
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19
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Bougouin W, Lascarrou JB, Dumas F, Cariou A. Targeted temperature management after cardiac arrest: the longer, the better? J Thorac Dis 2018; 10:49-51. [PMID: 29600019 DOI: 10.21037/jtd.2017.12.13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Wulfran Bougouin
- Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France.,Université Paris-Descartes-Sorbonne-Paris-Cité (Faculté de Médecine), Paris, France.,Paris Sudden-Death-Expertise-Centre, Paris, France
| | | | - Florence Dumas
- Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France
| | - Alain Cariou
- Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France.,Université Paris-Descartes-Sorbonne-Paris-Cité (Faculté de Médecine), Paris, France.,Paris Sudden-Death-Expertise-Centre, Paris, France.,Medical ICU, Cochin Hospital, AP-HP, Paris, France
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20
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Stanger D, Mihajlovic V, Singer J, Desai S, El-Sayegh R, Wong GC. Editor's Choice-Effects of targeted temperature management on mortality and neurological outcome: A systematic review and meta-analysis. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 7:467-477. [PMID: 29172657 DOI: 10.1177/2048872617744353] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
AIMS The purpose of this study was to conduct a systematic review, and where applicable meta-analyses, examining the evidence underpinning the use of targeted temperature management following resuscitation from cardiac arrest. METHODS AND RESULTS Multiple databases were searched for publications between January 2000-February 2016. Nine Population, Intervention, Comparison, Outcome questions were developed and meta-analyses were performed when appropriate. Reviewers extracted study data and performed quality assessments using Grading of Recommendations, Assessment, Development and Evaluation methodology, the Cochrane Risk Bias Tool, and the National Institute of Health Study Quality Assessment Tool. The primary outcomes for each Population, Intervention, Comparison, Outcome question were mortality and poor neurological outcome. Overall, low quality evidence demonstrated that targeted temperature management at 32-36°C, compared to no targeted temperature management, decreased mortality (risk ratio 0.76, 95% confidence interval 0.61-0.92) and poor neurological outcome (risk ratio 0.73, 95% confidence interval 0.60-0.88) amongst adult survivors of out-of-hospital cardiac arrest with an initial shockable rhythm. Targeted temperature management use did not benefit survivors of in-hospital cardiac arrest nor out-of-hospital cardiac arrest survivors with a non-shockable rhythm. Moderate quality evidence demonstrated no benefit of pre-hospital targeted temperature management initiation. Low quality evidence showed no difference between endovascular versus surface cooling targeted temperature management systems, nor any benefit of adding feedback control to targeted temperature management systems. Low quality evidence suggested that targeted temperature management be maintained for 18-24 h. CONCLUSIONS Low quality evidence supports the in-hospital initiation and maintenance of targeted temperature management at 32-36°C amongst adult survivors of out-of-hospital cardiac arrest with an initial shockable rhythm for 18-24 h. The effects of targeted temperature management on other populations, the optimal rate and method of cooling and rewarming, and effects of fever require further study.
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Affiliation(s)
- Dylan Stanger
- 1 Department of Medicine, University of British Columbia, Canada
| | - Vesna Mihajlovic
- 1 Department of Medicine, University of British Columbia, Canada
| | - Joel Singer
- 2 School of Population and Public Health, University of British Columbia, Canada
| | - Sameer Desai
- 2 School of Population and Public Health, University of British Columbia, Canada
| | - Rami El-Sayegh
- 2 School of Population and Public Health, University of British Columbia, Canada
| | - Graham C Wong
- 3 Division of Cardiology, University of British Columbia, Canada
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21
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Kirkegaard H, Søreide E, de Haas I, Pettilä V, Taccone FS, Arus U, Storm C, Hassager C, Nielsen JF, Sørensen CA, Ilkjær S, Jeppesen AN, Grejs AM, Duez CHV, Hjort J, Larsen AI, Toome V, Tiainen M, Hästbacka J, Laitio T, Skrifvars MB. Targeted Temperature Management for 48 vs 24 Hours and Neurologic Outcome After Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA 2017; 318:341-350. [PMID: 28742911 PMCID: PMC5541324 DOI: 10.1001/jama.2017.8978] [Citation(s) in RCA: 229] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE International resuscitation guidelines recommend targeted temperature management (TTM) at 33°C to 36°C in unconscious patients with out-of-hospital cardiac arrest for at least 24 hours, but the optimal duration of TTM is uncertain. OBJECTIVE To determine whether TTM at 33°C for 48 hours results in better neurologic outcomes compared with currently recommended, standard, 24-hour TTM. DESIGN, SETTING, AND PARTICIPANTS This was an international, investigator-initiated, blinded-outcome-assessor, parallel, pragmatic, multicenter, randomized clinical superiority trial in 10 intensive care units (ICUs) at 10 university hospitals in 6 European countries. Three hundred fifty-five adult, unconscious patients with out-of-hospital cardiac arrest were enrolled from February 16, 2013, to June 1, 2016, with final follow-up on December 27, 2016. INTERVENTIONS Patients were randomized to TTM (33 ± 1°C) for 48 hours (n = 176) or 24 hours (n = 179), followed by gradual rewarming of 0.5°C per hour until reaching 37°C. MAIN OUTCOMES AND MEASURES The primary outcome was 6-month neurologic outcome, with a Cerebral Performance Categories (CPC) score of 1 or 2 used to define favorable outcome. Secondary outcomes included 6-month mortality, including time to death, the occurrence of adverse events, and intensive care unit resource use. RESULTS In 355 patients who were randomized (mean age, 60 years; 295 [83%] men), 351 (99%) completed the trial. Of these patients, 69% (120/175) in the 48-hour group had a favorable outcome at 6 months compared with 64% (112/176) in the 24-hour group (difference, 4.9%; 95% CI, -5% to 14.8%; relative risk [RR], 1.08; 95% CI, 0.93-1.25; P = .33). Six-month mortality was 27% (48/175) in the 48-hour group and 34% (60/177) in the 24-hour group (difference, -6.5%; 95% CI, -16.1% to 3.1%; RR, 0.81; 95% CI, 0.59-1.11; P = .19). There was no significant difference in the time to mortality between the 48-hour group and the 24-hour group (hazard ratio, 0.79; 95% CI, 0.54-1.15; P = .22). Adverse events were more common in the 48-hour group (97%) than in the 24-hour group (91%) (difference, 5.6%; 95% CI, 0.6%-10.6%; RR, 1.06; 95% CI, 1.01-1.12; P = .04). The median length of intensive care unit stay (151 vs 117 hours; P < .001), but not hospital stay (11 vs 12 days; P = .50), was longer in the 48-hour group than in the 24-hour group. CONCLUSIONS AND RELEVANCE In unconscious survivors from out-of-hospital cardiac arrest admitted to the ICU, targeted temperature management at 33°C for 48 hours did not significantly improve 6-month neurologic outcome compared with targeted temperature management at 33°C for 24 hours. However, the study may have had limited power to detect clinically important differences, and further research may be warranted. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01689077.
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Affiliation(s)
- Hans Kirkegaard
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Eldar Søreide
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Inge de Haas
- Department of Anesthesiology and Intensive Care Medicine, Aalborg University Hospital, and Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Ville Pettilä
- Division of Intensive Care, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Urmet Arus
- Department of Intensive Cardiac Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Hassager
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jørgen Feldbæk Nielsen
- Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Denmark
| | - Christina Ankjær Sørensen
- Department of Anesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Susanne Ilkjær
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Denmark
| | - Anni Nørgaard Jeppesen
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anders Morten Grejs
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Christophe Henri Valdemar Duez
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Jakob Hjort
- Department of Clinical Medicine, Aarhus University, Denmark
| | - Alf Inge Larsen
- Department of Cardiology, Stavanger University Hospital, Norway
- Department of Clinical Science, University of Bergen, Norway
| | - Valdo Toome
- Department of Anesthesiology, Intensive Care and Emergency Medicine, North Estonia Medical Centre, Tallinn, Estonia
| | - Marjaana Tiainen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Finland
| | - Johanna Hästbacka
- Division of Intensive Care, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Timo Laitio
- Department of Anesthesiology and Intensive Care, Turku University Hospital and University of Turku, Finland
| | - Markus B. Skrifvars
- Division of Intensive Care, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University Melbourne, Australia
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22
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Jeppesen AN, Hvas AM, Duez CHV, Grejs AM, Ilkjær S, Kirkegaard H. Prolonged targeted temperature management compromises thrombin generation: A randomised clinical trial. Resuscitation 2017; 118:126-132. [PMID: 28602694 DOI: 10.1016/j.resuscitation.2017.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 05/26/2017] [Accepted: 06/05/2017] [Indexed: 11/16/2022]
Abstract
AIM To investigate whether prolonged compared with standard duration of targeted temperature management (TTM) compromises coagulation. METHODS Comatose survivors after out-of-hospital cardiac arrest (n=82) were randomised to standard (24h) or prolonged (48h) duration of TTM at 33±1°C. Blood samples were drawn 22, 46 and 70h after attaining the target temperature. Samples were analysed for rotational thromboelastometry (ROTEM® (EXTEM®, INTEM®, FIBTEM® and HEPTEM®)) and thrombin generation using the Calibrated Automated Thrombogram® assay. RESULTS With the 22-h sample, we revealed no difference between groups in the ROTEM® and thrombin generation results beside a slightly higher EXTEM® and INTEM® maximum velocity in the prolonged group (p-values≤0.04). With the 46-h sample, ROTEM® showed no differences when using EXTEM®; however, 11% (p<0.01) longer clotting time and 12% (p<0.01) longer time to maximum velocity were evident in the prolonged group than in the standard group when using INTEM®. The prolonged group had reduced thrombin generation compared with the standard group as indicated by 30% longer lag time (p=0.04), 106nM decreased peak concentration (p<0.001), 36% longer time to peak (p=0.01) and 411 nM*minute decreased endogenous thrombin potential (p<0.001). With the 70-h sample, no differences in ROTEM® results were found between groups. However, the prolonged group had reduced thrombin generation indicated by longer lag time, decreased peak concentration and longer time to peak (all p-values≤0.02) compared with the standard group. CONCLUSION Prolonged TTM in post-cardiac arrest patients impairs thrombin generation. ClinicalTrials.gov identifier: NCT02258360.
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Affiliation(s)
- Anni Nørgaard Jeppesen
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000 Aarhus C, Denmark.
| | - Anne-Mette Hvas
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Christophe Henri Valdemar Duez
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000 Aarhus C, Denmark
| | - Anders Morten Grejs
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000 Aarhus C, Denmark
| | - Susanne Ilkjær
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Hans Kirkegaard
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000 Aarhus C, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
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Kirkegaard H, Rasmussen BS, de Haas I, Nielsen JF, Ilkjær S, Kaltoft A, Jeppesen AN, Grejs A, Duez CHV, Larsen AI, Pettilä V, Toome V, Arus U, Taccone FS, Storm C, Skrifvars MB, Søreide E. Time-differentiated target temperature management after out-of-hospital cardiac arrest: a multicentre, randomised, parallel-group, assessor-blinded clinical trial (the TTH48 trial): study protocol for a randomised controlled trial. Trials 2016; 17:228. [PMID: 27142588 PMCID: PMC4855491 DOI: 10.1186/s13063-016-1338-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 04/06/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The application of therapeutic hypothermia (TH) for 12 to 24 hours following out-of-hospital cardiac arrest (OHCA) has been associated with decreased mortality and improved neurological function. However, the optimal duration of cooling is not known. We aimed to investigate whether targeted temperature management (TTM) at 33 ± 1 °C for 48 hours compared to 24 hours results in a better long-term neurological outcome. METHODS The TTH48 trial is an investigator-initiated pragmatic international trial in which patients resuscitated from OHCA are randomised to TTM at 33 ± 1 °C for either 24 or 48 hours. Inclusion criteria are: age older than 17 and below 80 years; presumed cardiac origin of arrest; and Glasgow Coma Score (GCS) <8, on admission. The primary outcome is neurological outcome at 6 months using the Cerebral Performance Category score (CPC) by an assessor blinded to treatment allocation and dichotomised to good (CPC 1-2) or poor (CPC 3-5) outcome. Secondary outcomes are: 6-month mortality, incidence of infection, bleeding and organ failure and CPC at hospital discharge, at day 28 and at day 90 following OHCA. Assuming that 50 % of the patients treated for 24 hours will have a poor outcome at 6 months, a study including 350 patients (175/arm) will have 80 % power (with a significance level of 5 %) to detect an absolute 15 % difference in primary outcome between treatment groups. A safety interim analysis was performed after the inclusion of 175 patients. DISCUSSION This is the first randomised trial to investigate the effect of the duration of TTM at 33 ± 1 °C in adult OHCA patients. We anticipate that the results of this trial will add significant knowledge regarding the management of cooling procedures in OHCA patients. TRIAL REGISTRATION NCT01689077.
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Affiliation(s)
- Hans Kirkegaard
- />Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Bodil S Rasmussen
- />Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Inge de Haas
- />Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Jørgen Feldbæk Nielsen
- />Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Hammel, Denmark
| | - Susanne Ilkjær
- />Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Kaltoft
- />Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Anni Nørregaard Jeppesen
- />Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anders Grejs
- />Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Christophe Henri Valdemar Duez
- />Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Alf Inge Larsen
- />Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
- />Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Ville Pettilä
- />Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital and Helsinki University, Helsinki, Finland
- />Intensive Care, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Valdo Toome
- />Department of Anesthesiology, Intensive Care and Emergency Medicine, North Estonia Medical Centre, Tallinn, Estonia
| | - Urmet Arus
- />Department of Intensive Cardiac Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Fabio Silvio Taccone
- />Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Christian Storm
- />Department of Internal Medicine, Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Markus B. Skrifvars
- />Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Eldar Søreide
- />Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
- />Department of Clinical Medicine, University of Bergen, Bergen, Norway
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